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Hypertension

Hypertension. Dr. Stella Yiu Staff Emergency Physician. LMCC objectives: Hypertension. Diagnose and determine severity Investigate target organ damage and 2 nd causes List medical management ( po and iv). 1. Diagnosis. Cdn 2012 guidelines. > 160 or > 100 x 3 Or > 140 or > 90 x 5 .

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Hypertension

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  1. Hypertension Dr. Stella Yiu Staff Emergency Physician

  2. LMCC objectives: Hypertension • Diagnose and determine severity • Investigate target organ damage and 2nd causes • List medical management (po and iv)

  3. 1. Diagnosis

  4. Cdn 2012 guidelines • > 160 or > 100 x 3 • Or • > 140 or > 90 x 5

  5. Most HTN = Essential HTN • 5-10% 2nd – curable • More demand on pump • or • Stiff pipes

  6. 2. 2nd causes

  7. 2nd Causes: Cardiac output (pump demand) • Renal failure + fluid overload • ++ aldosterone • Aortic coarctation

  8. 2nd Causes: Vascular resistance (stiff pipes) • Renal artery stenosis • Pheochromocytoma • Drugs • Brain (CVA, ICH, SAH)

  9. MCQ 8: What is the most common treatable 2nd cause for HTN? • Hyperaldosteronism • Renal artery stenosis • Pheochromocytoma • Aortic coarctation • Sympathomimetic use

  10. CDMQ: What are the clinical clues and investigations for 2nd causes?

  11.  Cardiac output (pump stress) • Renal failure + fluid overload • ++ Aldosterone • Aortic coarctation

  12.  Vascular resistance (stiff pipes) • Renal artery stenosis • Pheochromocytoma • Drugs • Brain (CVA, ICH, SAH)

  13. Investigations • Renal failure + fluid overload • Creatinine, CXR

  14. Investigations • ++ aldosterone • High Na, Low K • Cushingoid on exam

  15. Investigations • Aortic coarctation • HTN in Upper extremity • Systolic murmur over back • Delayed Femoral Pulse • Echo, Angio

  16.  Vascular resistance (stiff pipes) • Renal artery stenosis • Young female + fibromusculardysplasia • Resistant to HTN meds • Most common treatable cause • Abdobruits, low K, Abdo US

  17.  Vascular resistance (stiff pipes) • Pheochro-mocytoma • Episodes of • HTN + HA + palp +diaphoresis • Urine catecholamines, metanephrines

  18.  Vascular resistance (stiff pipes) • Drugs • Amphetamines, sympathomimetics • MAOI • Clinical exam: toxidrome • Urine tox • ECG

  19.  Vascular resistance (stiff pipes) • Brain • (CVA, ICH, SAH) • CT head

  20. 3. Manage HTN emergency

  21. What are the target organs?

  22. What are the target organs?

  23. MCQ 9: Which is not an HTN emergency? • 35 M 220/140, dizzy, normal neuro exam • 50 M 200/120, chest pain, CXR wide mediastinum • 25 F 28 wks pregnant, 150/80, seizure • 80 F 220/120, left arm weakness • 45 F 200/120, crackles to apex, JVP 6cm

  24. Aortic Dissection Pulmonary edema ACS

  25. Bleeds, seizures Encephalopathy (not just headache, dizzy) Acute renal failure

  26. CDMQ: List Investigations for HTN emergency

  27. Investigations for HTN emergency Aortic Dissection ARF Pulmonary edema ACS Bleeds, seizure, encephalopathy

  28. Treat HTN emergency: General • BP: Reduce MAP by 25% • Iv medications: • Labetolol • Nitroprusside • Hydralazine

  29. CDMQ: 45 F 220/120, bilateral crackles, JVP 6cm, Sat 80%, treatment?

  30. Specific Treatment: Pulmonary Edema • BiPAP • Nitrates iv • Furosemide iv

  31. Specific Treatment: ACS • ASA • NTG • Beta-blockers

  32. Specific Treatment: Dissection • Iv Nitroprusside + beta-blocker • Iv labetolol • Surgery if ascending aorta

  33. Specific Treatment: Seizure+ preg (Eclampsia) • MgSO4 • Iv Hydralazine • Delivery

  34. 3. Manage HTN in Ambulatory setting

  35. Diagnosis • > 160 or > 100 x 3 or • > 140 or > 90 x 5

  36. MCQ 10: What test is not needed in ambulatory testing for HTN? • Urine, urine albumin (DM) • Lytes+ creatinine • Fasting glucose + cholesterol • CBC + diff • ECG

  37. Treatment HTN ambulatory • Non-pharmacological management

  38. First line med, dosage and side effects? • No other comorbidities? • CAD? • Diabetes? • Asthma? • Renal failure?

  39. No co-morbid – 1st line • Thiazide (HCTZ 251) • Beta-blocker (Metoprolol 252) • CCB (Amlodipine 51) • ARB (Losartan 25mg )

  40. DM • + Renal: ACEI/ARB • CCB • Thiazide

  41. Asthma • Avoid beta-blocker

  42. CRF (non-DM) • ACEI/ARB • Thiazide

  43. CAD • ACEI /ARB • Angina/recent MI: Beta-blocker

  44. Improving compliance • Fit daily routine • Once daily dosing • Single pill combination • Dosette

  45. LMCC objectives: Hypertension • Diagnose and determine severity • Investigate target organ damage and 2nd causes • List medical management (po and iv)

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